Chapter 48: Skin Integrity and Wound Care

Skin Integrity and Wound Care begins by examining the anatomy of the skin, including the epidermis and dermis, and explores how age-related changes, such as reduced elasticity and collagen, affect tissue tolerance. A significant portion of the text is dedicated to the pathogenesis of pressure injuries, explaining how pressure intensity, duration, and tissue tolerance contribute to tissue ischemia and cell death. It details critical risk factors, including impaired sensory perception, immobility, shear, friction, and moisture, while defining specific conditions like Medical Device-Related Pressure Injuries (MDRPI) and Medical Adhesive-Related Skin Injury (MARSI). The chapter thoroughly outlines the National Pressure Injury Advisory Panel staging system, distinguishing between Stage 1 nonblanchable erythema, Stage 2 partial-thickness skin loss, Stage 3 and Stage 4 full-thickness tissue loss, unstageable injuries obscured by slough or eschar, and deep-tissue pressure injuries characterized by deep red or maroon discoloration. It contrasts acute versus chronic wounds and differentiates healing processes by primary, secondary, and tertiary intention. The physiological phases of full-thickness wound repair—hemostasis, inflammation, proliferation, and remodeling—are described in depth, along with potential complications such as hemorrhage, hematoma, infection, dehiscence, and evisceration. Clinical assessment strategies are provided, highlighting the use of the Braden Scale for predicting risk and methods for measuring wound dimensions, undermining, tunneling, and exudate types like serous, purulent, and sanguineous drainage. The text also covers nutritional requirements essential for healing, emphasizing the importance of calories, protein, vitamin C, vitamin A, and zinc. Furthermore, it explores evidence-based nursing interventions for prevention and treatment, including positioning techniques like the 30-degree lateral turn, the selection of therapeutic support surfaces, wound irrigation, and various debridement methods. It concludes with a detailed guide on wound management using Negative-Pressure Wound Therapy (NPWT) and the application of diverse dressings such as hydrocolloids, hydrogels, foams, and calcium alginates, alongside safety guidelines for heat and cold therapy applications.